OMB control number

Certified Community Behavioral Health Clinic-Expansion (CCBHC-E)

OMB 0930-0402 ยท 0930.

OMB 0930-0402

SAMHSA is requesting clearance for eleven data collection instruments and forms related to the implementation and impact studies to be conducted as part of the evaluation. The evaluation will provide new information about how grants support adoption of the CCBHC model, how grants influence sustainable expansion of CCBHC capacities beyond the grant period, and how implementation of the model influences client-level outcomes. An evaluation of the IA and PDI grantees specifically provides an opportunity to examine implementation successes and challenges within each area of the certification criteria among a larger and more diverse group of clinics operating in different state and community contexts. By carefully measuring that context and how it changes over time, the evaluation can provide new information about how factors such as alternative sources of funding and state/community support for the model can influence implementation and outcomes. Finally, this evaluation has an opportunity to assess changes in quality of care and longitudinal client-level health, behavioral health, and functional outcomes.

The latest form for Certified Community Behavioral Health Clinic-Expansion (CCBHC-E) expires 2028-05-31 and is listed under ICR 202412-0930-003.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form Consumer Family Me Consumer/Grantee/Clinic InterviewsForm and Instruction
Form GPO Interview Prot GPO InterviewForm and Instruction
Form Grantee Survey Rou Grantee SurveyForm and Instruction
Form Parents Caregiver Focus GroupsForm and Instruction
Form Client Interview Client InterviewForm and Instruction
CCBHC-E CSE OMB Package - Supporting Statement A.docxSupporting Statement A
Attachment K3 Parent Caregiver of Youth Client Focus Group Introduction Script.docx Supplementary Document
Attachment J3 Youth Client Focus Group Introduction Script.docx Supplementary Document
Attachment I3 Adult Client Focus Group Introduction Script.docx Supplementary Document
Attachment H3 Clinic Partner Organization Interview Introduction Script.docx Supplementary Document
Attachment G3 Clinic Staff Interview Introduction Script.docx Supplementary Document
Attachment F3 Clinic Leadership Interview Introduction Script.docx Supplementary Document
Attachment E3 Grantee Project Director Interview Introduction Script.docx Supplementary Document
Attachment D3 Consumer and Family Member Organization Interview Introduction Script.docx Supplementary Document
Attachment C3 GPO Interview Introduction Script.docx Supplementary Document
Attachment I4 Focus Group Sign-In Sheet.docx Supplementary Document
Attachment F5 Site Visit Schedule.docx Supplementary Document
Attachment F4 Site visit email communications.docx Supplementary Document
Attachment C4 Interview email communications.docx Supplementary Document
Attachment A2 Grantee Web Survey Reminder Email.docx Supplementary Document
Attachment K2 Parent Caregiver of Youth Client Focus Group Consent.docx Supplementary Document
Attachment L2 Client Wellness Interview Questions SAMPLE Consent.docx Supplementary Document
Attachment J2a Youth Client Focus Group Parental Consent.docx Supplementary Document
Attachment J2 Youth Client Focus Group Assent.docx Supplementary Document
Attachment I2 Adult Client Focus Group Consent.docx Supplementary Document
Attachment H2 Clinic Partner Organization Interview Consent.docx Supplementary Document
Attachment G2 Clinic Staff Interview Consent.docx Supplementary Document
Attachment F2 Clinic Leadership Interview Consent.docx Supplementary Document
Attachment E2 Grantee Project Director Interview Consent.docx Supplementary Document
Attachment D2 Consumer and Family Member Organization Interview Consent.docx Supplementary Document
Attachment C2 GPO Interview Consent.docx Supplementary Document
CCBHC-E CSE OMB Package - Supporting Statement B.docxSupporting Statement B
Consumer/Grantee/Clinic Interviews Form and Instruction
GPO Interview Form and Instruction
Grantee Survey Form and Instruction
Focus Groups Form and Instruction
Client Interview Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202412-0930-003 New collection (Request for a new OMB Control Number) 2024-12-13 Approved with change

OMB Details

Client Interview

Federal Enterprise Architecture: Health - Public Health Monitoring

Information collection instruments
FormNameElectronic accessType
Form Client InterviewClient InterviewFillable FileableForm and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.